what we know about electronic nicotine delivery...
TRANSCRIPT
What We Know About Electronic Nicotine Delivery Systems (ENDS)
National Center for Chronic Disease Prevention and Health Promotion Office on Smoking and Health
Brian King, PhD, MPH
Deputy Director for Research Translation
Office on Smoking and Health
State Health Directors Conference January 22, 2016 ● Raleigh, North Carolina
Overview
What are Electronic Nicotine Delivery Systems (ENDS)?
Who is Using ENDS?
What are the Health Effects of ENDS?
What are some ENDS Policy Options?
What are Electronic Nicotine Delivery Systems (ENDS)?
Electronic Nicotine Delivery Systems (ENDS)
At least 450 Brands
E-Cigarettes
E-Cigars
E-Pipes
Hookah Pens
Vape Pens
E-Hookahs
Types of ENDS Products
Smaller/Fixed Larger/Customizable
Anatomy of an E-Cigarette
Battery (power source)
Atomizer (heats the solution)
User inhales aerosol
Liquid Cartridge (holds a liquid nicotine, propylene
glycol, and/or glycerin solution)
Emissions from ENDS
Mainstream (Exhaled) Aerosol
E-cigarette Advertising Expenditures, by Media Channel, 2011−2012
Source: Kim et al. E-cigarette Advertising Expenditures in the U.S., 2011–2012. Am J Prev Med. 2014;46:409-412.
2013: >$80 million 2014: >$115 million
Marked Increases in the Sale of ENDS (2012-2013)
Source: Loomis BR, Rogers T, King BA, Dench DL, Gammon DG, Fulmer EB, Agaku IT. National and State-Specific Sales and Prices for Electronic Cigarettes – United Sttaes, 2012-2013. Am J Prev Med. 2015 June 29. Epub ahead of print.
In convenience stores, dollar sales increased:
320.8% for disposable e-cigarettes 72.4% for starter kits
82% for cartridges
In food, drug, and mass merchandisers, dollar sales increased: 49.5% for disposable e-cigarettes
89.4% for starter kits
126.2% for cartridges
Who is Using ENDS?
Ever Use of E-cigarettes among U.S. Adults, by Cigarette Smoking Status, Styles, 2010-2013
9.8
36.5
2.5 9.6
1.3 1.2 0
10
20
30
40
50
60
2010 2011 2012 2013
Per
cen
t (%
)
Year
Current Smoker
Former Smoker
Never Smoker
Source: King, Patel, Nguyen, and Dube. Trends in Awareness and Use of Electronic Cigarettes among U.S. Adults, 2010-2013 Nicotine Tob Res ntu191 first published online September 19, 2014 doi:10.1093/ntr/ntu191
Source: CDC/NCHS, National Health Interview Survey, 2014. http://www.cdc.gov/nchs/data/databriefs/db217.htm
Percentage of U.S. adults who currently use e-cigarettes, by sex, age, and race/ethnicity, 2014
Past 30 day use of e-cigarettes among U.S. adults, by cigarette smoking status – Styles,
2010/2011 & 2012/2013
0.2 1.0 1.0 1.3
4.9
9.4
0
5
10
15
20
Per
cen
t
Never Smoker
Former Smoker
Current Smoker
2010/2011 2012/2013
Never Smoker
Former Smoker
Current Smoker
Source: King, Patel, Nguyen, and Dube. Trends in Awareness and Use of Electronic Cigarettes among U.S. Adults, 2010-2013 Nicotine Tob Res ntu191 first published online September 19, 2014 doi:10.1093/ntr/ntu191
76.8% of current e-cigarette users were also current cigarette smokers in 2012/2013
“Cutting Back” is Not Enough
Sources: Bjartveit K, Tverdal A. Health Consequences of Smoking 1-4 Cigarettes per Day. Tobacco Control 2005; 14(5):315-20. Tverdal A, Bjartveit K. Health Consequences of Reduced Daily Cigarette Consumption. Tobacco Control. 2006; 15(6): 472–80.
Risks for Dual Users of Cigarettes and E-Cigs
Smoking just 1-4 cigarettes per day doubles risk of dying from heart disease
Heavy smokers who reduce cigarette use by half still have very high risk for early death
Benefits of Completely Quitting
Heart disease risk cut in half 1 year after quitting
This risk continues to drop over time
Quitting at age 50 cuts your risk in half for early death from a smoking-related disease
1.5 0.6
2.8 1.1
4.5
1.1
13.4
3.9
High School Middle School
2011 2012 2013 2014
Current (Past 30 Day) Use of E-cigarettes among U.S. Middle and High School Students, 2011-2014
Source: Centers for Disease Control and Prevention & U.S. Food and Drug Administration. National Youth Tobacco Survey.
E-cigarettes and Nonsmoking Youth
Source: Bunnell, Agaku, Arrazola, Apelberg, Caraballo, Corey, Coleman, Dube, and King. Intentions to smoke cigarettes among never-smoking U.S. middle and high school electronic cigarette users, National Youth Tobacco Survey, 2011-2013 Nicotine Tob Res.
From 2011-2013, the number of “never smoking” youth who used an e-cigarette increased three-fold.
The intention to smoke conventional cigarettes was also higher among
e-cigarette users.
Among Youth, E-cigarette Use May Lead to Conventional Cigarette Use
High school students who had never smoked but reported ever using e-cigarettes at baseline were 2.7 times more likely to start using combustible tobacco after 1 year compared with high school students who never used e-cigarettes
U.S. adolescents and young adults who had never smoked but used e-cigarettes at baseline were 8.3 times more likely to progress to cigarette smoking after 1 year than nonusers of e-cigarettes
Sources: Leventhal AM, Strong DR, Kirkpatrick MG, et al. JAMA 2015; Primack BA, Soneji S, Stoolmiller M, et al. JAMA Pediatr 2015
What Factors Lead to Youth Smoking?
Exposure to ads
Youth-resonating themes
Low prices/price promotions
Ease of access
Youth-appealing flavors
Health claims
Ease of product use
Source: DHHS. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA. 2012.
A Majority of Current Youth E-cigarette Users Report Using Flavored E-cigarettes
Among U.S. middle and high school
students who currently use e-cigarettes,
63% have used flavored e-cigarettes
(1.58 million U.S. youth)
Source: Corey CG , Ambrose BK, King BA, and Apelberg BJ. MMWR October 2015
ENDS Marketing Uses Traditional Tactics
1940’s / 1950’s 2010’s
Source: www.tobaccodocuments.org.
ENDS Advertising Via Television
Source: Philip Morris USA; Blu Ecigs
1970 2013
Source: Singh et al. Vital Signs: Exposure to Electronic Cigarette Advertising Among Middle School and High School Students — United States, 2014. MMWR. 2016.
Marketing ENDS to Treat Psychiatric Symptoms
Source: Smokeless Cigarettes Blog, March 8, 2012. http://www.smokelessdelite.com/electronic-cigarettes-reduce-depression
What are the Health Effects of ENDS?
“The century-long epidemic of cigarette smoking has caused an enormous avoidable public health
tragedy”
1964 2014
Significant Questions Remain About:
Source: The health consequences of smoking – 50 years of progress: a report of the Surgeon General. – Atlanta, GA. : U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
1) How to assess the potential toxicity and health effects of the more than
250 electronic cigarettes brands;
2) The magnitude of the potential reduced risk from electronic cigarettes versus continuing use of conventional cigarettes for individual smokers;
3) The need to weigh the potential individual benefits and risks versus population benefits and risks;
4) How the advertising and marketing of these new products should be regulated and;
5) Even assuming that electronic cigarettes could be sufficiently safe to users and offer net public health benefits, there are significant questions about the manner in which they should be regulated.”
Chapter 16, page 873
Could have negative and positive individual and population health impact
“This shift in patterns of tobacco use could have a number of potential impacts, ranging from the positive effect of accelerating the rate at which smokers quit smoking cigarettes completely to a negative effect of slowing down the decrease in the use of all tobacco products, especially cigarettes” Chapter 15, Page 859
Source: The health consequences of smoking – 50 years of progress: a report of the Surgeon General. – Atlanta, GA. : U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
2014 Surgeon General’s Report: ENDS
ENDS Potential for Harm if:
Leads to initiation of
combustible tobacco use among non-
smokers, particularly
children
Leads to relapse among former
smokers
Diminishes the chances
that a smoker will
quit
Discourages smokers
from using proven quit
methods
Exposes children, pregnant
women, and non-users to secondhand
aerosol
Glamorizes or
renormalizes tobacco use
Results in poisonings
among users or non-users
Harmful and Potentially Harmful Ingredients in ENDS Aerosol
Volatile Organic
Compound
Heavy Metals
Fine Particulate
Nicotine
Other Compounds
Nicotine Poses Unique Dangers to the Developing Human
Source: England, Lucinda J et al. Nicotine and the developing human: A neglected element in the electronic cigarette debate. Am Journ Prev Med 2015.
Nicotine is toxic to developing fetuses and
impairs fetal brain and lung development
Nicotine use while adolescent brain is
developing can disrupt brain circuit formation
Poisonings occur among users via ingestion of
nicotine liquid, absorption through skin, and inhalation
ENDS can be Modified to Accommodate Other Psychoactive Substances
Source: NBC New York. http://www.nbcnewyork.com/news/local/ECigarettes-Drugs-Marijuana-Vapor-Pens-Smoking-I-Team-227269001.html
"I was on the train from New York to Baltimore and I enjoyed the pen the whole way there and back with no one noticing," said one life-long marijuana user who asked not to be identified. "I absolutely was thinking 'This is not bad at all.”
Number of calls to poison centers for cigarette or e-cigarette
exposures, by month – U.S., September 2010–February 2014
Source: Centers for Disease Control and Prevention. Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes — United States, September 2010–February 2014. Morbidity & Mortality Weekly Report. 2014;63:292-293.
Is there a potential benefit for ENDS?
Complete long term substitution by established smokers
Assist in rapid transition to a society with little or no use of combustible products
Short-term use if shown to produce successful and permanent cessation of combustible products
Only under certain
circumstances
What are Some ENDS Policy Options?
Changing the Cost-Benefit Calculus
• Tobacco easily accessible
• Smoking in public legal
• Unfettered advertising
• Poor access to cessation help
• Cigarettes designed to addict
Individual
Tobacco Addiction
Society
Changing the Cost-Benefit Calculus
Individual
Tobacco Addiction
Society
• Tobacco more expensive and less accessible
• Smoke-free policies
• Counter-marketing and promotion restrictions
• Easy access to help
• Cigarettes made less addictive
Family Smoking Prevention and Tobacco Control Act
Granted FDA the authority to regulate tobacco products
Enhances the ability to intensify policy to reduce tobacco industry influence
Manufacturing
Marketing
Sale Photo: AFP/GETTY
Signed into law on June 22, 2009
Evidence-Based Interventions are Key
Prevent Youth Access
Marketing and sales that result in youth using ENDS should
not be tolerated
Prohibit the
sale of ENDS
to minors
Require childproof
packaging and retail licensure
States with* and without laws prohibiting sales of electronic nicotine delivery systems (ENDS) to minors** United States,
October 2015
Does Not Prohibit ENDS Sales to Minors (n=6)
Prohibits ENDS Sales to Minors (n=45)
*Includes some codified laws which have not yet been implemented. ** Minors are defined by statute as persons <18 years, except in four states where they are defined as persons aged <19 years (Alabama, Alaska, New Jersey, and Utah) and one state where they are defined as persons aged <21 years (Hawaii).
D.C.
Evidence-Based Interventions are Key: Protect Clean Indoor Air Standards
ENDS aerosol is not “harmless water vapor.”
ENDS aerosol contains nicotine, as well as additional toxins, and is not as safe as clean air.
Clean air—free of smoke and ENDS aerosol—protects the health of bystanders, prevents tobacco use initiation among youth, and encourages complete smoking cessation.
States with and without laws prohibiting smoking and use of electronic nicotine delivery systems (ENDS) in indoor areas of
private worksites, restaurants, and bars - United States, October 2015
No Comprehensive Smoke-Free Law or Prohibition on Indoor ENDS Use (n=24)
Prohibits Indoor Smoking and Indoor ENDS Use (n=6)
Prohibits Indoor Smoking Only (n=21)
D.C
Recent CDC Research on ENDS Escalating Youth Use Over Time:
Notes from the Field: Electronic Cigarette Use Among Middle and High School Students—United States, 2011-2012 (MMWR 2014)
Tobacco Use Among Middle and High School Students—United States, 2013 (MMWR 2013)
Tobacco Use Among Middle and High School Students—United States, 2011-2014 (MMWR 2015)
Adult Trends in Awareness and Use: Trends in Awareness and Use of Electronic Cigarettes Among US Adults, 2010–2013.
Nicotine and Tobacco Research 2014; 17(2):219-227.
Advertising and Flavors among Youth: Vital Signs: Exposure to Electronic Cigarette Advertising Among Middle School and
High School Students — United States, 2014Flavored
Tobacco Product Use Among Middle and High School Students — United States, 2014
Recent CDC Research (Continued)
ENDS Use and Increased Intentions to Smoke: Intentions to Smoke Cigarettes Among Never-Smoking U.S. Middle and High
School Electronic Cigarette Users, National Youth Tobacco Survey, 2011-2013 (Nicotine and Tobacco Research 2013)
Illustrating the Harms of Nicotine: Notes from the Field: Calls to Poison Control Centers for Exposure to Electronic
Cigarettes—United States, September 2010-February 2014 (MMWR 2014)
Nicotine and the Developing Human: A Neglected Element in the Electronic Cigarette Debate (AJPM 2015)
Highlighting what States have Done: State Laws Prohibiting Sales to Minors and Indoor Use of Electronic Nicotine
Delivery Systems — United States, November 2014 (MMWR 2014)
ENDS Fact Sheets http://www.cdc.gov/tobacco/stateandcommunity/index.htm
Summary
ENDS are unregulated and are not an FDA-approved quit aid.
Youth and adult ENDS use is increasing rapidly.
Youth use of nicotine or tobacco in any form is dangerous.
Adults must quit smoking cigarettes completely to realize potential benefits of ENDS.
Policy Approaches No marketing or sales to kids
Clean air is the standard
FDA regulation is important, but states, localities, and tribes shouldn’t wait to act
Pedal to the metal on combustible tobacco
Key Take Away Points
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: [email protected] Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Brian A. King, PhD, MPH
Office on Smoking and Health
National Center for Chronic Disease Prevention and Health Promotion
Office on Smoking and Health
Contact
(770) 488-5107
www.cdc.gov/tobacco